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HomeMy WebLinkAbout1249A ,,, WORKERS'COMPENSATION OKLARATION � � I heteby cffirm �hot I hove o certifica�e of con�ent to eelf �� �insure,or a cerlificale of Workeri Compensation Insurance,or �ea6dao ��� a�e�,;f;��o y Ihereof�Sec.3800,tob C.) CE808�REV 1/8J� APPLICATION FOR PERMIT Policy No.B�CGOS��onyAi ghl anAa -r.,�„rance Co. S E W E R - S E W A G E D I S P O S A L I ❑Ce�fified copy ia hereby furnishad. � � �Cer�ified copy is f�led wirh the counry building inspection UR1t5 41a 41 9��1�T U 4�S�ELES BUILDING ANDSAFETV de rtme�t �ore ��25�87 n�i��a�� �►atore Plumbing, I FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION fROM WORKERS' eunoinc ZZ9Z7 Estoril Dr. sr�rion oevrH COMVENSATION INSURANCE �oocess (Th�s ucrion need no�be compkied if ihe work invoived by tha i�,i�n. Diamond Bar MAMKKF RFffllfNf� � UPPER permit is for one h�ndred dollare(3100)or less.� � a 1 ce�tify tho�in the px�ormonce of�he wo�k fo�which�his ;sssr. Porto Grande dII(� Montefino nPF���T� ��TM�� erm�t is�swed,I sholl not em lo on � Y� curze V L, M.L.TO P.t. p p y y person in ony monner v C� so as to become sub�ecl to the Workers'Compenwtion laws. o,�,f,�EQ Amatore Plumbing� ZIIC. �p,i�r.p � �� Ah1Poo�eess 17791 Mitchell South TRUNKiFRMITNp. ROADPERMRNO. oo�� aPPi��om NOTICE TO APMICANT: If, aNer mo4ing this Certificate of �ir Irvine ,F�.,,�.660-0660 AfFIDAVIi wMVER tws¢r.�NT rt�cpap,iNsm.ra, o�h Ezemp�ion, you sho�ld become s�bject to ihe Workeri iEwi �Compenwtion provisions of the Labor code,you mus�forthwi�h pescaivnani ior r+o. � ' Hwr,oe st.wwer+rtre � � �ply with s�th provisions or this permil shnll be deemed . r kBd. BtOCN TPA�f $IATE ENCQOACHMENT - � LICENSED CONTRACTORS DECLARATION r�o.a�ocs. �aMiT r�o. - SIZF OF LOT NOW ON lpT I hereby affirm that I om licensed under provisions of Chopter 9(commencing wilh Secfion 7000)of Division 3 of the B�sl- p�it i�GS COI1f105 p�,��5 . ness ond Professions Code,ond my license iz in full force and • eifec�. ca+rRacroR �atore Plumbing� Ine. [pNNER�ONCHARGEffE licensaNi�mber 355068 �tC.C�d55 �—�� ADDRf55 127 W. State ��'�UiSEMENTiEE � Contro�f�ore P1UIDb1�g• IRC. 8/25/87 oTv Ontario . ,E,.,,,o. 986-5878 oisraicTr+o. ca+ouv inwv wrocessEoer O BK PG V . STAiE LiC. { p 1 om esempt under$et. of fhe L.A.Co. ucpNg r�o. a�55 4� R�� �c��0 A `Q O �'+0. OESCRI7TION OF WORK fEE F,,, PlumbingCode and/or Sec. of the r�wi rj ����R�COMNKTINGTO 17.00 ea 85 00 °ATE �/� VAIIDATION w � B.6 P.Code for�he following reoson r�ra■,st[vw�t v�r pt � y VITS AND/�R�RAINilElO FMAI ' Z Da+e Mp�$E SEy�ER CONNECTING 10 �Y nRNATE W51'OS/LL SvStEM $i9nO�ur! CONNEQ ADDITIONAL&DG.OR ► ' OWNER-BUILDERDECIARATION u�o�Krowous[s¢wtR G/fQFIOW SEEPAGE NT.ORAMIfIFlO :'� C�n p �1 hereby affirm thor I am exempr Trom�he Contractor's License E1cW.,CESSq70l,ORYW[LL hMNIIOIE � y low for�he following reason(Secton 7031.5,Bu�sness and Pro• ar[a,�vr,iR oe nealloor�Housc n ,� . IQSSiOM COdl�: SEWER OR DISVOS�L SYSIEM !i :�• • •�•� O � n I as owner o(the prope�ty,or my employees with wages as � �lheir sole compenso�ion,will do the work and�he structure . � • ��l J�b� ls nor imended or offered for sole(Seciio�7044,Business permit f 1� 5� • ° •9 a 5 0� and Profess�ons Code). OWNER'S ❑I,as owner of the property,am exclusively contraUing wi�h AUTHORIZATION TOTAL FEE r o ft 3 1 -8 7 ��Cl�SOd COIIIlO[�OfS 10 C0031NC1 II12 PlO�BCI�SBC�10��Od4, �pqyF qT TMI$DAiF A CONIRACI WITX 711E MF4FIN W.MED COMTRKTpt ro - ' 8�siness and Professions CodeJ. tonir�ecr Twe nsovt oescaie�o[xrsnNc ov.Fuwc To rH[weuc stw[a. . CONSTRUCTION LENDING AGENCY , - I he�eby offirm Ihal there is e construttion lending ogency ��EDTHIS DAYOF � 19_ for the performance o( �he work for whitb 1hi5 permit is ��Rce � � OWNER$AGFN7 issued($ec.3097,Civ.C.). lender's Nome aooac55 Lender a Address . � I tertify 1Fwt I have read this applicotion and stoie thot Ihe obove information is correct.I agree lo tomply wifh all County � ordinonces and Slale laws reguloting Plumbing and Sewers, ond heraby thaize representatives of�his County to en�er upon the ve- tioned pr�p�ny for inspecei n purposes. � /� .SiqnoWre o mitle Dole SEE REVERSE FO�E%rIANATORY IANGUAGE LU3lSS—J�...�1���Q_` . � ' � z, � r��c� .: � �^N • a�.et z ' - ' . .:.y. u���i f a, ��['�1 �v ;if ��m Y� . . • . � ' `c(��Lt Gt.� c� 3� 'C! . • . � . �' `•.'; '�.' i`.i `^ 'j.7 ' , .., ',. ; Z: �+� '.Q ,•'_ 4_ O .' :1 , ' ='^ �`;. `�l: i� `s,; � G `� G �'�: '�r�', %� :^ ',�� ;:� r'° � •�, ' ,`. l�.� x� �„�;A .;� �,� �',`�, � ` ' ` �� �� N n C `^ � , :. �, � ',� � �,� _ . �,o ,���; - - � '� ; � , ; �` u � �``�� ; - � , ; ! `,, . - , —� �. � . . � _ ... � , . } '�` ,, - , `� - , 1 � _, ', . , , ;,. _` - , , , , ' . , . � �'' _ � ,,':• , ,,. 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